Management of Psychiatric Disorders during the Perinatal Period.

INTRODUCTION

The psychiatrist working in a general hospital psychiatric unit has several opportunities for consultation-liaison work with the obstetrician. There is a bidirectional relationship between psychiatry and obstetrics. While on one hand, the improved management of psychiatric illness is helping many more women with mental illness embrace motherhood; on the other hand, psychiatrists often receive referrals for the evaluation of women undergoing treatment for infertility or Assisted Reproductive Techniques (ART) or antenatal and postnatal care. From the obstetrician’s point of view, the major contributors to maternal mortality in the past were obstetric complications such as hemorrhage and medical disorders complicating pregnancy such as diabetes mellitus and hypertension. However, with improved obstetric care protocols and a significant reduction of maternal mortality rates due to obstetric and medical diseases, maternal mental health has come to the fore as one of the major contributors to morbidity and mortality.

A psychiatrist may receive a referral for consultation in three broad situations:

Either as an out-patient referral from the antenatal or postnatal clinic of obstetrics;

In the obstetric in-patient or labor room; or

From the obstetric emergency services.

This article is organized as follows:

First, we would like to give a broad overview of the various conditions that may be seen in the context of the perinatal period, including the medical disorders that can lead to these presentations and the suggested investigations. Second, we present a format for clinical assessment. Third is a note on the general principles of management in the perinatal setting, including a note on the risk-benefit analysis of medications and management planning.

Fourth is a section on the management of individual disorders in the perinatal period.

Finally, we cover other conditions such as management of suicidal risk, agitation, the use of electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (RTMS), and the future role of mother–baby units (MBUs) in general hospital psychiatry.

OVERVIEW OF PSYCHOLOGICAL CONDITIONS IN THE PERINATAL PERIOD

Preconception

In the preconception stage, there are broadly three groups of patients who may be referred for evaluation: (i) Patients undergoing treatment for infertility or ART who may be referred for psychological issues such as stress, anxiety, and depression; (ii) Patients with previous traumatic experiences during pregnancy and childbirth; (iii) those with preexisting psychiatric illness.

Patients who are undergoing treatment for infertility and those with previous traumatic experiences during childbirth, such as injuries during labor, disrespectful care during labor, stillbirth, or requirement for emergency interventions including Caesarean section may be at risk for psychological morbidity such as depression and anxiety. Patients with preexisting psychiatric illnesses may need a review of their clinical condition and decision on continuation, modification, or discontinuation of medication will have to be taken.

During pregnancy referrals may be received for women with new onset of a psychiatric condition, preexisting mental illness, or for psychological distress caused by psychosocial factors such as marital discord, domestic violence, or substance use in spouse.

Events around childbirth, such as stillbirth can lead to grief. There may be psychological distress related to gender of the infant. Medical illness in the infant and separation of mother and infant due to NICU admission may also lead to psychological distress including anxiety, anticipatory grief.

In the postpartum period, disorders of mother–infant bonding may be there. Mood-related changes may present as postpartum blues or postpartum depression (PPD). Postpartum psychosis (PPP) is a particularly severe form of behavioral disturbance that may be seen in the postpartum period.

Tables 1 and 2 present an overview of the various conditions seen in the perinatal period.

Table 1

Overview of perinatal psychiatric conditions for which consultation may be sought

Context or risk factors	Psychosocial factors	Psychiatric conditions
Preconception
Infertility and ART	Psychological effects of medications or treatment Excessive worries Marital discord	Anxiety Depression
Trauma during childbirth/disrespectful care/perinatal loss/emergency caesarean section	Tokophobia – fear of pregnancy and childbirth Excessive worries about pregnancy and foetal health	Anxiety PTSD Grief Mother-infant bonding disorders
Women with pre-existing SMI such as schizophrenia, bipolar disorder or recurrent depressive disorders, planning for pregnancy	Fear of teratogenic or other adverse effects of medications Pressure from family to stop prophylactic medications Inability to follow-up regularly	High risk of recurrence (60-80%) of SMI without medication prophylaxis. With medication prophylaxis, the risk is about 20-30%
Pregnancy
Pre-existing psychiatric illness, on prophylaxis with accidental exposure to psychotropics	Concerns about teratogenic or other adverse effects Abrupt discontinuation of medications poses risk of relapse Review treatment Screen for major congenital anomalies Watch for medical comorbidities	High risk of recurrence (60-80%) of SMI without medication prophylaxis. With medication prophylaxis, the risk is about 20-30%
New onset of psychiatric illness during pregnancy	Hesitation to take medications	Anxiety - 10%-15% Depression - 15-20%
Poor family support, substance use disorder in spouse and domestic violence	Previous female child Marital discord	Anxiety Depression PTSD
Childbirth
Sickness in infant/separation from infant admitted to NICU/stillbirth	Worries about health of infant Separation anxiety, guilt Anticipatory grief	Anxiety and PTSD Depression Grief
Stress related to gender of infant	Previous female child Family expectations for male infant Can lead to domestic violence or marital discord	Adjustment disorder, depression

ART – Assisted reproductive techniques; PTSD – Posttraumatic stress disorder; SMI – Severe mental illness; NICU – Neonatal intensive care unit

Table 2

Overview of postpartum psychiatric conditions

Postpartum
Condition and prevalence	Presentation	Suggested interventions
Difficulties in mother infant bonding (5% of healthy mothers; 40-60% of mothers with psychiatric illness)	Mild disorders – delay, absence or loss of bonding Pathological anger – verbal or physical aggression Anxiety regarding care of infant – may not trust others with care of infant Rejection – rare	Mild disorders – reassurance or encouraging interactions with infant, contact with infant Pathological anger – ensure safety and rule out mania or psychosis Anxiety regarding care of infant – allay anxiety
Postpartum blues (40-50%)	Mild, self-limiting, and associated with emotional changes that may or may not progress to depression	Reassurance Adequate social support
Postpartum depression (15-20%)	May be insidious in onset in first few months after childbirth In bipolar disorder, abrupt onset of psychotic depression may be noted	In mild cases, it may improve with psychotherapy alone but may require antidepressant treatment in moderate to severe cases
Postpartum psychosis (1-2/1000 live births)	Abrupt onset of behavioral disturbances presenting as (i) mania with psychotic symptoms; (ii) psychotic depression; (iii) acute psychosis; or (iv) catatonia	Requires risk assessment for suicidal and infanticidal risk In-patient care may be required
Obsessive–compulsive disorder	It may pertain to cleaning-contamination or to obsessive urges or impulses to harm the infant (without actual incidences of harm)	Mild cases may be managed with CBT Anti-obsessional medications (SSRI) may be required in severe symptoms

CBT – Cognitive behavior therapy; SSRI – Selective serotonin reuptake inhibitors

OUTLINE OF CLINICAL ASSESSMENT OF PERINATAL PSYCHIATRIC CONDITIONS

When the psychiatrist is called for the evaluation of the obstetric patient, the psychiatric evaluation may proceed along the following lines [outlined in Box 1].

Box 1

Clinical assessment in perinatal psychiatry history

History

History of current illness, ongoing symptoms, and functioning

History of medical and neurological illnesses - to rule out thyroid disorder, hypertension, diabetes mellitus, seizures/epilepsy, headache, visual disturbances, fever with altered sensorium, signs of connective tissue disease such as skin lesions or gum bleeds, arthritis

Past history of episodes of psychiatric illness

Treatment history for prior episodes

Relevant family, developmental and personal history

Assessment of the premorbid personality

Past pregnancies and their outcomes

History of traumatic pregnancies and any past obstetric violence especially in severe labor related anxiety or PTSD

History of child sexual abuse or sexual assault

Enquiry must be made into certain aspects of pregnancy such as if it is: Planned/unplanned pregnancy, wanted/unwanted pregnancy; a precious pregnancy, and if the woman has specific worries about her own health or the fetus’ health

Enquiry is made into details about spouse and family members and the available support

History of substance use disorders in the woman as well as spouse must be enquired as the latter is a risk factor for domestic violence and psychological morbidity

Examination

Physical examination must be tuned to detect common medical conditions seen in pregnancy

General examination must look for pallor, jaundice, blood pressure, pedal edema, thyroid enlargement, skin for signs of bleeding

Systemic examination must evaluate cardio-respiratory system for any cardiac conditions, neurological examination and for arthritis or other signs of connective tissue disorders

Mental status examination as per routine psychiatric evaluation

Particular emphasis is placed on attitudes towards pregnancy, motherhood, concerns, and worries about pregnancy or infant health

Any psychopathology (depressive cognitions, delusions, or hallucinations) relating to the infant is specifically noted in this setting

Suicidal risk assessment and risk of harm to infant is also documented

Diagnosis is made using standard criteria such as ICD-10 or DSM-5

Psychometric tools may be used for the suggested purposes

For anxiety - Screening: GAD-7[1]; Severity: HARS[2]

For depression - Screening: Whooley’s questions[3], PHQ-9[4], EPDS[5], HDRS[6]; Severity: EPDS, HDRS

For mania - severity: YMRS[7]

For psychotic illnesses and schizophrenia – PANSS[8], SAPS[9] and SANS[10]

For severe mental illnesses – BPRS[11]

For assessment of maternal behavioral disturbance - NIMBUS[12]

For mother-infant bonding disorders – PBQ[13]

Structured clinical interview (for research in perinatal psychiatry)

The stafford interview[14] is a detailed interview schedule with nine parts. The first four parts form the prepartum section including the psychosocial context of pregnancy and the next five parts forms the postpartum section beginning with labour/childbirth and mother-infant bonding. The interview schedule provides probe questions along with answers with anchor points that help to rate the severity of the clinical findings. One or more sections of the interview schedule may be applied in isolation for specific clinical or research purposes (eg., Mother-infant bonding section to assess the mother-infant bonding)

PTSD – Posttraumatic stress disorder; GAD-7 – General anxiety disorder-7; HARS – Hamilton Anxiety Rating Scale; Patient Health Questionnaire; EPDS – Edinburgh Postnatal Depression Scale; HDRS – Hamilton Depression Rating Scale; YMRS – Young Mania Rating Scale; PANSS – Positive and Negative Symptoms Scale for Schizophrenia; SAPS – Scale for Assessment of Positive Symptoms; SANS – Scale for Assessment of Negative Symptoms; BPRS – Brief Psychiatric Rating Scale; NIMBUS – National Institute of Mental Health and Neuro Sciences; NIMBUS – NIMHANS Maternal Behaviour Scale; PBQ – Postpartum Bonding Questionnaire; ICD – International Classification of Diseases; DSM – Diagnostic and statistical manual of mental disorders

History includes a routine psychiatric history and in addition, specific history pertaining to the perinatal context is elicited. This includes a history of past pregnancies and their outcomes, including traumatic pregnancies, obstetric complications, and perinatal loss. Current pregnancy details including psychosocial context of pregnancy, support from spouse and family as well as a history of substance use and domestic violence is collected. Care is taken to ensure privacy to the woman and family members as they may not be forthcoming with a history of psychological symptoms in a crowded emergency room or in the obstetric ward.

Physical examination should be conducted to rule out organic etiology of the psychiatric presentation. Some of the common etiological possibilities such as hypertension, anemia, jaundice, thyroid disorders, connective tissue disorders, movement disorders, cerebral and cerebrovascular disorders must be ruled out. In addition to clinical examination, certain investigations [Table 3] and referrals to other specialists may be advised to the obstetrician.

Table 3

Suggested laboratory investigations for diagnosis of common medical conditions occurring in the perinatal period

Diagnosis	Investigation
Infections	Complete blood count
	Blood culture
	Urine culture
	Wound site discharge culture
Dyselectrolytemia	Serum sodium
	Serum potassium
	Blood calcium and parathormone (if indicated)
Uremia	Blood urea
	Serum creatinine
	eGFR
Diabetes mellitus	Blood glucose levels
Diabetic ketoacidosis	Urine ketones
Hypoglycemia	HbA1c
Anemia	Hemogram with MCV, peripheral blood smear examination
	Serum Iron
	Serum Vitamin B12 levels
Thyroid dysfunction	TSH, (T3, T4 if indicated)
Autoimmune thyroiditis	Anti-thyroid antibodies
Hepatitis	Serum bilirubin, SGOT, SGPT, ALP
Hepatic encephalopathy	USG abdomen
	Serum ammonia
Substance use disorders	Urine drug screen
Central nervous system diseases	CT brain (with contrast if indicated). CT is avoided during pregnancy
Head injury/stroke/hypertensive encephalopathy/PRES/cortical venous thrombosis	MRI Brain EEG
Sheehan syndrome/Wernicke encephalopathy/acute demyelinating encephalomyelitis/multiple sclerosis, Anti-NMDA receptor encephalitis	CSF analysis (lumbar puncture)
Meningitis/encephalitis

PRES – Posterior reversible encephalopathy syndrome; EEG – Electroencephalogram; NMDA – ; eGFR – Estimated glomerular filtration rate; HbA1c – Hemoglobin A1c; CT – Computed tomography; MRI – Magnetic resonance imaging; TSH – Thyroid-stimulating hormone; SGOT – Serum glutamic-oxalacetic transaminase; SGPT – Serum glutamic-pyruvic transaminase; ALP – Alkaline phosphatase; USG – Ultrasonography; CSF – Cerebrospinal fluid; MCV – Mean corpuscular volume

Mental status examination can be done using the routine format used for general psychiatric evaluation. Particular note must be made if the patient has confusion, perplexity, or even frank disorientation as these may alert us to a medical/neurological etiology. Attention is given to the presence of delusions related to the infant or the presence of hallucinations that refer to the infant. These may have a bearing on the risk assessment that is done. Cognitive functions can be assessed as part of the routine mental status examination and followed up with further structured cognitive assessments which can help us assess the possibility of an organic etiology.

Risk assessment should include an assessment of risk of suicide, infanticidal risk, and risk of harm to others. In every case, a specific enquiry must be made about suicidal ideas, plans, or any recent attempts of suicide. We may also use structured tools for the assessment of suicide risk. This may include the IS PATH WARM? Signs[15] or any other structured tool for assessment of suicidal risk. Mothers with severe mental illness (SMI) in the postpartum period may have infanticidal ideas and risk for infant harm. The presence of a depressive disorder and suicidality as well as psychotic symptoms related to the infant can lead to risk of harm to the infant.[16] Mothers with postpartum mania may handle the infant in a rough manner leading to potential injuries to the infant. They may also be verbally or physically aggressive to the infant during the irritable phase.

Table 4 lists some psychopathology specific to the perinatal period and its clinical implications.

Table 4

Psychopathology related to the infant and its implications

Psychopathology	Implications
Delusion that fetus is already dead	Psychotic depression
Or regarding ill health/major defects in the infant	Acute psychotic states
Or that infant has died but the facts are hidden from her (in case of NICU admissions)	Often associated with maternal medical conditions also
Delusions that her infant is blessed or divine or special	Mania
Those others may try to steal the infant	Acute psychotic states
	Can lead to clinging to infant and rough handling with potential for injuring the infant
Denial of pregnancy	Schizophrenia
	Psychotic depression
	Following sexual assault
	Intellectual disability
	Poor co-operation during childbirth
	Usually resolves with treatment
Hallucinations	Command hallucinations may lead to harm to infant or being overprotective and clinging
Negative symptoms	Emotional neglect
Catatonic symptoms	Lack of bonding with infant
	Under-stimulation of infant may ensue
Agitation	Poor feeding, rough handling of infant
Anger toward infant or physical abuse	Disorders of mother-infant bonding (pathological anger and rejection type)
Borderline states	Anxiety-related to safety of infant and bonding problems
Complex trauma

NICU – Neonatal intensive care unit

Psychometric tools [Table 5] are helpful in the objective assessment of the patient’s clinical condition and can help monitor the treatment outcomes. While some scales are useful for screening in the antenatal setting, others are useful in rating the severity of psychopathology. Finally, some scales are particularly designed for research purposes use in specialized in-patient peripartum psychiatry settings; they assess constructs such as maternal behavior and mother–infant bonding or have been adapted for the peripartum setting.

Table 5

Psychometric tools that may be useful in perinatal psychiatry

Name of the tool	Method of administration	Purpose	Number of items, time taken to apply	Available in	Settings it may be used
GAD-7[1]	Self-rated	Screening for anxiety	7 items 5 min	English, Hindi	OG/OP/IP
HARS[2]	Clinician administered	Rating severity of anxiety	14 items 10 min	English	IP/OP
Whooley’s questions[3]	Two-question screen	Screening for perinatal depression	2 questions 2 min	English	OG
EPDS[5]	Clinician administered	Screening for and rating of severity of depression	10 items 10 min	English, Punjabi	OG/OP/IP
PHQ-9[4]	Self-rated or clinician administered	Screening for and rating of severity of depression	9 items 10 min	English, Assamese, Gujarati, Hindi, Malayalam, Oriya, Telugu	OG/OP/IP
HDRS[6]	Clinician administered	Rating of the severity of depression	17-item version is commonly used 20 min	English	IP/OP
YMRS[7]	Clinician administered	Rating of severity of mania	10-item 10 min	English	IP/OP
PANSS[8]	Clinician administered	Rating of severity of positive, negative, and general psychopathology measures in psychotic disorders	7-items positive subscale; 7-items negative subscale; 16-item general psychopathology subscale	English	IP
SAPS[9]	Clinician administered	Severity of positive symptoms of psychosis	34-item (over 4 subscales 30-40 min	English	IP
SANS[10]	Clinician administered	Severity of negative symptoms of psychosis	25-item (over 5 subscales) 30–40 min	English	IP
Brief Psychiatric Rating Scale[11]	Clinician administered	Severity of psychopathology in severe mental illnesses including mania, acute psychosis, or schizophrenia	18-item 20-30 min	English	IP
NIMBUS[12]	Clinician administered	Severity of maternal behavioral disturbance	16-items (across 6 sub-domains) 10-15 min	English	IP/R
PBQ[1318]	Self-rated or Clinician assisted	Screening for disorders of mother-infant bonding	25-item 15-20 min	English, Tamil	IP/R
Stafford interview[14]	Interview schedule	Covers eight domains from pregnancy to lactation	2-4 h as per the number of sections administered	English, Kannada	IP/R

IP – Psychiatry in-patient; OP – Psychiatry out-patient; OG – Antenatal clinic or obstetric consultation-liaison setting; IP/R – Specialised MBU or research settings; GAD – General anxiety disorder; HARS – Hamilton Anxiety Rating Scale; EPDS – Edinburgh Postnatal Depression Scale; PHQ-9 – Patient health questionnaire-9; HDRS – Hamilton Depression Rating Scale; YMRS – Young Mania Rating Scale; PANSS – Positive and Negative Symptoms Scale for Schizophrenia; SAPS: Scale for assessment of positive symptoms; SANS – Scale for Assessment of Negative Symptoms; NIMHANS – National Institute of Mental Health and Neuro Sciences; NIMBUS – NIMHANS Maternal Behaviour Scale; PBQ – Postpartum bonding questionnaire; MBUs – Mother-baby units

ROUTINE SCREENING FOR DEPRESSION AND ANXIETY IN THE ANTENATAL AND POSTNATAL PERIOD

While universal screening may tend to overestimate the prevalence of psychosocial disorders or even unduly raise the alarm in the case of false-positive screen (~35%–40%), the Marce International Society position paper recommends that a basic inquiry into current symptoms using the Whooley’s questions, Patient Health Questionnaire-9[4] or Edinburgh Postnatal Depression Scale[5] along with inquiry about past and family history of psychiatric disorders may be useful.[17] The Whooley’s questions[3] are the first two questions of PRIME-MD, namely: (1) In the past 1 month, have you felt down, depressed or hopeless? (2) In the past 1 month, have you been bothered by little interest or pleasure in things?

The offer for screening must be backed up with adequate resources to provide timely and appropriate services required for the woman (including appropriate referrals to secondary or tertiary care centers). In larger centers with multi-disciplinary teams, this may be possible within the hospital, however, obstetricians working in smaller centers without in-house counselors or mental health professionals may refer the women appropriately.

Psychometric tools specific for the peripartum setting such as specialized MBUs or research purposes include the NIMHANS Maternal Behaviour Scale for rating maternal behavior and the Postpartum Bonding Questionnaire which is helpful in screening for disorders of mother–infant bonding. The Stafford Interview is a detailed interview schedule useful in MBUs and for research purposes. Table 5 lists some psychometric tools that may be used in perinatal psychiatry. We also suggest the settings in which the scales may be used.

GENERAL APPROACH TO THE PATIENT IN PERINATAL PSYCHIATRY

If the woman consults during the preconception period, and the woman is still symptomatic, we may advise the couple to delay pregnancy. They can plan for pregnancy once the clinical condition stabilizes.

In case the woman is on medications and is asymptomatic, a trial of discontinuation may be attempted for women who have a history of mild illness such as a mild depressive episode in the past. The risk of relapse and the need for early review in case of relapse has to be emphasized in such cases. It is beneficial if there is a supportive caregiver at home who can detect early signs of relapse and bring the patient for management in the event of relapse.

In case of SMI, prophylactic medications are preferable even if the patient is presently asymptomatic. A medication which is relatively safe in pregnancy and lactation may be chosen. We may need to taper and discontinue medications that are adjunctive in nature and no longer required. This may include benzodiazepines, beta-blockers, and anticholinergic agents. The decision to change the medication to another one with greater safety data may not be required in every case unless the risks of continuing the current medication are high for the given patient. However, abrupt discontinuation of medications must be avoided. Folic acid 5 mg/day is prescribed in all women who are planning for pregnancy.

When a woman presents for consultation during pregnancy, we must emphasize that early and regular antenatal check-up and planning childbirth at a hospital with adequate facilities for maternal and neonatal care, including neonatal intensive care is preferable especially if the mother is taking psychotropic medications. All mothers on psychotropic medications are advised to undergo anomaly scans in early trimester (10–12 weeks) as well as at 16–18 weeks when fetal echocardiography can also be done especially for mothers who are on medications that may be associated with a risk of congenital cardiac defects (e.g., selective serotonin reuptake inhibitor [SSRI], lithium).

If it is not a planned pregnancy and there were no prior opportunities to modify the medications in the preconception period, medications may be modified as outlined above. For new onset of psychiatric disorder during pregnancy, psychotherapy is preferred for mild illness in the first trimester. However, in case of persistent or worsening symptoms and in women with severe course of illness, medication may be initiated.

Since pregnancy can alter the pharmacokinetics of medications, there may be a need for dose adjustments. A slow rate of gastric emptying and increased intestinal transit time can delay the absorption of orally administered medications. Increased plasma volume, lower lean muscle to adipose tissue, and changes in plasma protein binding leads to greater volume of distribution for lipophilic medications. Medications that undergo hepatic metabolism are cleared faster due to increase in CYP450 enzyme activity and Phase 2 enzyme activity (Uridine diphosphate Glucoronoyl Transferase) and increased steroid hormone levels. Medications that undergo renal clearance undergo greater clearance due to a higher glomerular filtration rate.

These pharmacokinetic changes may require the following precautions [Table 6].

Table 6

Pharmacokinetic considerations in pregnancy

Medication	Changes seen	Precautions to be taken
Antidepressants	Levels may fall in late pregnancy (after 20 weeks)	Symptoms monitoring and if possible drug level monitoring
Lithium	Increase in GFR and fluid volume reduces lithium level throughout pregnancy and immediately returns to prepregnancy level soon after delivery	Check Li levels monthly till 34 weeks, weekly thereafter until delivery Consider repeating lithium blood levels before and 24 h after delivery (if adequate fluid balance during labor was not maintained) Assess lithium levels frequently in initial few weeks postpartum
Lamotrigine	May decrease around 50% due to increase sex steroids levels, phase 2 metabolic enzyme UGT Folic acid supplementation may reduce effects of lamotrigine	Serum level monitoring from preconception until first month of postpartum

GFR – Glomerular filtration rate; UGT – Uridine diphosphate glucuronosyl transferase

LACTATION ADVICE

Prefer a minimum number of medications, preferably monotherapy in lactation. The medications which have low relative infant dose (RID) (preferably <10%) are compatible with breastfeeding. Since the medications achieve a steady state level after a few days of treatment, there is no need for withholding breastfeeding for a few hours after each dose of medications. On-demand breastfeeding is recommended. The infant should be monitored for signs of medication-related toxicity such as excessive sedation, floppiness, respiratory depression, cyanosis (with sedatives), or excessive crying, irritability, diarrhea, jitteriness, seizures (with antidepressants), and for rigidity, poor suck reflex, poor feeding, irritability (with antipsychotics). Breastfeeding may have to be withheld in case of any signs of toxicity and a review of medication done. In case of preterm or low birth-weight neonates or neonates with medical or surgical disorders, the advice of the pediatrician or neonatologist may be sought regarding the safety of breastfeeding. This is important because the metabolism of medications may be affected in neonates with these conditions and they may be at greater risk of adverse effects as compared to healthy neonates who are born at term and have normal weight.

One of the concerns with the use of psychotropic medications has been a possible delay in infant development.[19] However, the developmental delay is usually mild and is reversible with the infant catching up with the peers once the exposure to psychotropic medication stops after weaning. Moreover, such delays were more common in low-birth-weight or premature infants or those born to elderly mothers.[20] In view of this, general advice must be given regarding adequate stimulation of infants. This would include ensuring that the mother or another caregiver is able to provide adequate sensorimotor stimulation to the infant in the form of massage and oil bath, singing lullabies, cooing and talking the infant, providing a variety of colors and sounds through toys, providing an emotional attachment figure to the infant in cases where the mother has severe negative symptoms or sedation due to medications. The possible risks of this mild and reversible delay outweigh the benefits of effective ongoing medications for SMI in the mother.

Figure 1 outlines the general approach to the woman depending on the context of referral. The general advice for the stage at which the woman is seen and general considerations in medical management are listed next.

Figure 1

General approach to management in perinatal psychiatry

RISK BENEFIT ASSESSMENT AND MANAGEMENT PLANNING

One of the concerns of medication use in perinatal psychiatry is regarding the potential harms of psychotropic medications on the pregnancy and fetal and neonatal outcomes. There is often hesitation among patients, caregivers, and other physicians to continue psychotropic medications during pregnancy. Some patients stop medications abruptly once they conceive and risk a relapse of psychiatric illness putting themselves and the fetus at risk.

A risk-benefit assessment with regard to the use of medications in the perinatal period becomes important along with planning of pregnancy to mitigate these risks. The four major considerations of risks and benefits to the mother and fetus/infant that need to be considered are:-(i) risks of untreated maternal psychiatric illness; (ii) benefits of avoiding medication exposure; (iii) benefits of adequate control of maternal illness; and (iv) risks of medications.

The risks of untreated maternal depression or SMI include the risk of poor adherence to antenatal care, self-neglect and neglect of infant, suicidal risk and/or infanticidal risk, poor nutrition, and physical disorders. Risk of domestic violence, substance use, and poor obstetric outcomes such as preterm labor, low birth weight, and stillbirth increase in patients who are symptomatic.

The risks of untreated maternal illness are weighed against the medication-related risks. Medication-related risks include the teratogenic potential of medications, potential for maternal morbidity, adverse fetal, neonatal, and childhood outcomes. In this section, we discuss some of these risks which can aid in decision-making regarding psychotropic medications.

The teratogenic risk categories for medications were formerly reported as Food and Drug Administration (FDA) categories from 1979 to 2015. Some representative medications and their FDA category are listed in Table 7.

Table 7

FDA categories of medications, safety indication, and medication lists

FDA category	Safety indication	Psychotropic medications in this category
A	Controlled studies have failed to demonstrate a risk to foetus in the first trimester or subsequent trimesters	Folic acid, Thyroxine
B	Animal studies have failed to demonstrate risk of harm to fetus but there are no human studies	Clozapine, Zolpidem, Bupropion, Buspirone
C	Evidence of risk to fetus in animal studies but no well-controlled studies in humans	Most antipsychotics (except clozapine), most antidepressants (except paroxetine), Lamotrigine
D	Evidence of risk of harm to the human fetus however, the drugs may be used in individual patients if the benefits exceed the harm	Lithium, valproate, carbamazepine, paroxetine and most benzodiazepines
X	Significant risk of harm to fetus and the risks exceed benefits	Benzodiazepine drugs such as temazepam, estazolam, flurazepam

FDA – Food and Drug Administration

These FDA categories were critiqued for being overly simplistic and misleading. They were replaced by the new Pregnancy and Lactation Labelling Rule[21] from June 30, 2015. The new rules categorize the risks into three headings:

Pregnancy-related risks are mentioned. This includes any information on disease-related risks to mother and fetus or embryo, any dose adjustments required during pregnancy, maternal adverse reactions, fetal/neonatal adverse reactions, and finally effects on labor and delivery

Lactation-related labeling includes details of the presence of drug and active metabolites in human milk, effects of drug on the infant, and effects of drug on breastfeeding itself. Information on minimizing exposure and monitoring for adverse effects is also listed

Females and males of reproductive potential. This section covers the advice regarding requirements for pregnancy testing, contraceptive use before or during drug therapy. It also includes information on the effect of the drug on reproductive potential.

These considerations help us to decide on medication management for psychiatric illnesses in pregnancy and postpartum.

Some key medication-related risks are conveyed to the woman and caregivers in terms of risk/potential for major congenital malformations, any increased risk of specific congenital malformations, or adverse maternal and fetal outcomes while comparing these risks with the risk of similar adverse outcomes in women who decide to discontinue medications during pregnancy. Dara from large registry-based studies has suggested that the risks of a particular adverse outcome may not be attributable to the medication itself and may be due to the underlying condition for which the medication is being prescribed. This is called as “confounding by indication.”

Table 8 lists the risks associated with some of the psychotropic medications with relative risks which can aid in patient education. However, it is pertinent to note that the evidence in this field is still emerging and it is important to review the latest evidence periodically and adapt the patient counseling accordingly.

Table 8

Summary of risks associated with psychotropic medications[1922]

Medications	Potential complications	Pregnancy-recommendations	Lactation-recommendation
Antidepressants	No increase in major congenital malformations (most data is for SSRIs) Spontaneous abortion, gestational hypertension and preeclampsia, low APGAR score at birth, low birth weight Third trimester use- neonatal withdrawal syndrome (these risks are minimal, not clinically significant, and confounded by underlying depression)	See individual medication class	Considered safe if RID is <10%
SSRI	Cardiac septal defects with 1st trimester exposure (most with paroxetine) PPHN with 3rd trimester exposure (low absolute risk 3 per 1000) Postpartum hemorrhage (SSRI may slight increase the risk) No increased risk of aneuploidy	Sertraline-least placental exposure Avoid paroxetine	Sertraline is preferred Fluoxetine may have RID (1.6-14.6%) and may need infant monitoring
TCA	Fetal exposure to TCA is high	Avoid doxepin	Amitryptiline, nortriptyline, desipramine, clomipramine are considered safe
MAO inhibitors	Congenital malformation/hypertensive crisis	Avoided in pregnancy	Little or no data
Antipsychotics	No increased risk of major congenital malformation	See under each drug class	See under each drug class
SGA Risperidone Aripiprazole Olanzapine Quetiapine Clozapine	Increased maternal weight gain Increased risk of gestational diabetes Increased birth weight Clozapine – risk of floppy infant syndrome	Monitor maternal weight gain OGTT USG for fetal growth Clozapine – monitor for agranulocytosis	Clozapine is contraindicated
FGA Haloperidol Chlorpromazine Trifluoperazine Fluphenazine	No major congenital malformation Low birth weight, preterm delivery Third-trimester exposure - extrapyramidal and withdrawal symptoms	High potency drugs preferred	Considered relatively safe
Mood stabilizers	Used as second-line agents in bipolar disorder (after SGA)
Lithium	Ebstein anomaly (1/1000)	May be used if benefits exceed the risks	Avoid breastfeeding, OR if breastfed, do foetal blood level monitoring (RID 12-30%)
Valproate	Major anomalies, neural tube defects (6-9%), intellectual disability in child	Avoided	RID (1.5%) Compatible with breastfeeding
Carbamazepine	Increased risk of malformation	Avoided	RID (1-7%) compatible with breastfeeding
Lamotrigine	No increase in risk of major congenital malformation	Therapeutic drug monitoring needed	RID 9.2-18.3% Considered safe with monitoring
Anxiolytics Benzodiazepines	May induce perinatal toxicity, low APGAR score, hypotonia, poor feeding, clef defect Just before delivery - floppy infant syndrome	Consider tapering BDZ Intermittent use less likely to cause any withdrawal Short-acting drugs preferred-Lorazepam	May cause sedation Short-acting agents preferred if required – Lorazepam (RID 2.5-3%)

RID – Relative infant dose; SSRIs – Selective serotonin reuptake inhibitors; PPHN – Persistent pulmonary hypertension of newborn; SGA – Second-generation antipsychotics; OGTT – Oral glucose tolerance test; FGA – First-generation antipsychotics; USG – Ultrasonography; BZD – Benzodiazepine; TCA – Tricyclic antidepressant; MAO – Monoamine oxidase

PROCESS OF DISCUSSION OF RISKS AND BENEFITS OF MEDICATIONS WITH MOTHERS AND THEIR FAMILIES

Once the clinical assessment is completed and a decision is made that the woman will have more benefits than risks of taking medications, the following discussion is suggested with the woman and family regarding the medication options [Box 2 and Figure 2].

Box 2

Discussion of medication risks and benefits

When

All women of childbearing age who are receiving psychotropic medications must be sensitized about risks and benefits of psychotropic medications

Preconception counselling may be initiated at the first visit when the woman plans to get married or presents after marriage

Most women present for consultation during pregnancy after psychotropic exposure has already occurred as the majority of pregnancies are unplanned or women have less control over contraception. Hence it is important to involve the woman and her partner in discussions regarding contraception and spacing of pregnancies

Women of child bearing age with a past or family history of mental illness or on psychotherapy may also be educated about it in case of future requirement

Whom

Counselling should include the woman and the primary caregivers especially the spouse, if available

Only if the woman does not have the capacity to decide, nominated representative/caregiver should be involved primarily in the discussion

Why

Most pregnancies are unplanned and psychotropics exposure to the foetus can be avoided

On unintended exposure, the woman and caregivers may stop medications abruptly leading to high risk of relapse in the case of SMIs

How

The possible medication options (individualised for the woman) may be listed out

The benefits of medication prophylaxis can be discussed. This includes relapse rates in women who receive prophylaxis as against those who discontinue prophylaxis for the given condition

The risks of relapse or untreated maternal mental illness on the outcomes of pregnancy and foetal-infant health can be discussed

This is followed by a discussion of potential risks and benefits of psychotropic medications

What

The specific details of risk where available can be given

Use of visual aids or charts can help

Information about embryonic/foetal development in each trimester of pregnancy and specific risks associated

The risks may be presented in terms of relative risk (i.e. the use of drug X increases the risk of cardiac defects to 1.4 times compared to that foetuses not exposed to drug X)

Absolute risks may be presented with a common denominator for ease of grasping – example given in

Exposure

In case of exposure to psychotropics in first trimester, decision to continue or change the medication and assessments for foetal anomalies must be done

Documentation

Brief documentation of the discussions held with the woman and caregivers, their concerns raised and clarifications given and their decision (if there are multiple options offered) may be documented

SMIs – Severe mental illness

Figure 2

Sample risk graphics to show risks during pregnancy

MANAGEMENT OF PSYCHIATRIC DISORDERS IN THE PERINATAL PERIOD

Common mental disorders include anxiety, depression and related disorders such as adjustment disorders are usually amenable to psychotherapy in the initial stages and when they are mild in severity. Therefore, the principle is to treat mild episodes of these disorders with psychotherapy alone. Cognitive behavior therapy (CBT) may help in anxiety as well as depression. Interpersonal psychotherapy may help in depression and exposure and response prevention (ERP) may be provided for treatment of obsessive–compulsive disorder. If the anxiety or depressive symptoms are persistent, recurrent or are worsening in severity; or if there is poor response to psychotherapy alone-medication may be prescribed for the management of the illness.

Anxiety disorders

Some women experience anxiety or stress related to infertility and treatment for infertility, previous pregnancy loss, fear of pain during labor (tokophobia), and concerns about traumatic experiences during pregnancy. In such cases, management involves psychoeducation, supportive counseling, and reassurance by obstetrician after due antenatal check-up. In case these measures do not help, more structured psychotherapy or medications may be considered as in the case of anxiety or depression.

SSRIs (except paroxetine) are the medication of choice for the management of anxiety disorders in pregnancy. Buspirone (FDA category B) does not have many human studies to support the use.

Depressive disorders

In the case of depressive disorders, the risk-benefit assessment for considering medication prophylaxis has the following considerations. Women who have had a single mild episode of depression in the past may be given a trial of discontinuation of antidepressant medications if they are asymptomatic for 6–12 months. However, those who have had a more severe illness such as recurrent (four or more lifetime episodes) of depression, or have had severe depression with psychotic symptoms, or had suicide attempts during the depressive episode or have required hospitalization or ECT for control of depressive symptoms in the past will benefit from continuing the antidepressant prophylaxis.[23] The presence of domestic violence and previous traumatic experiences increase the risk and the presence of adequate social support is a protective factor against depression.

Obsessive compulsive disorder

For mild severity of symptoms, previous response to ERP/CBT with prolonged remission and absence of significant comorbidity like depression may allow a trial of discontinuation of SSRI treatment. However, in more severely ill women with comorbid depression or suicidal risk, the risks of discontinuation of medication may exceed the benefits.

MANAGEMENT OF SEVERE MENTAL ILLNESS IN PERINATAL PERIOD

SMI refers to Bipolar affective disorder and schizophrenia. In the context of perinatal psychiatry, severe behavioral disturbances can also occur in PPP as well as PPD which is often of abrupt onset, with severe symptoms, psychotic symptoms, and suicidal risk.

The risk of relapse of bipolar disorder is as high as 66% in women who discontinue prophylaxis as opposed to about 25% among those who continue prophylaxis.[24] Women with schizophrenia are also advised to continue prophylaxis in the perinatal period. Second-generation antipsychotics (SGA) are preferred for prophylaxis. There is a risk of increased weight gain as well as gestational diabetes with SGA and women should be monitored for excessive weight gain and asked to undergo a glucose tolerance test during pregnancy.[19]

Bipolar disorder

Monotherapy with SGA is preferred as outlined above. In bipolar depression, there may be a need to add antidepressants for a short period in some women. Some women may require the addition of a mood stabilizer.

Valproate and carbamazepine are avoided during pregnancy due to the risks of congenital malformations and neurodevelopmental disorders.[25] However, low-dose lamotrigine (<325 mg/day) may not be associated with risk of major congenital malformations and may be continued in women with bipolar depression after discussing the risks and benefits.[26] Similarly, in women who have required lithium prophylaxis to remain well, it may be considered after discussion with the woman and caregivers. Therefore, when SGA alone is not effective as prophylaxis and a mood stabilizer is required, lithium or lamotrigine may be considered as per the woman’s clinical profile.

Relapse prevention strategies for bipolar disorder include: Avoiding sleep deprivation, stress management, ensuring medication adherence, avoiding substance use, and knowledge of early warning signs of a recurrence with self-monitoring of symptoms.

Schizophrenia

Monotherapy with antipsychotic medication is preferred for the management of schizophrenia. SGAs are usually preferred when treatment has to be initiated. While first-generation antipsychotics (FGAs) or long-acting injectable antipsychotics (LAI) are not initiated for treatment of schizophrenia during pregnancy. This is because there is less safety data regarding these medications. In case a woman is maintaining well on FGAs and a change of medications carries the risk of relapse, we may decide to continue the medications after discussion with the woman and family. In case a woman conceives while of effective treatment with LAI antipsychotics, the discontinuation may not immediately reverse the possibility of adverse effects as the clearance of these LAI drugs may take weeks after stopping treatment.[27] While most antipsychotics are compatible with breastfeeding and have RID <10%, clozapine is contraindicated in breastfeeding.

For the management of severe postpartum psychiatric conditions, medications compatible with lactation are preferred. PPD typically begins within the first 4 weeks following delivery, but the risk period can be up to 2 years’ postdelivery. In mild cases, it may be managed with antidepressants alone. In cases of psychotic depression, an antipsychotic is also prescribed. However, the bipolar disorder must be ruled out in women before prescribing antidepressants for long periods. Severe illness, where suicidal risk is high, may warrant in-patient care to ensure safety of the patient, infant and others family members. Women with a previous episode of PPD may be given prophylactic antidepressants in the postpartum period.

Brexanolone (allopregnanolone) is an endogenous progesterone metabolite which acts as an allosteric modulator of the GABA-A receptor. Brexanolone is recommended for moderate to severe PPD in a stepped dosing pattern as follows: 30 mg/kg/hour in first 4 h, followed by 60 mg/kg/h for next 20 h, then at a maximal dose of 90 mg/kg/h for next 28 h and then stepped down to 60 mg/kg/h for 4 h and 30 mg/kg/hour in the last 4 h. The administration of the requires close monitoring in an in-patient setting. Headache, dizziness, fainting, or syncope are the major adverse effects reported. The drug though approved by FDA is yet to be launched in India.

PPP is a SMI which has abrupt onset in the postpartum period (usually within 4–6 weeks of childbirth). It may present as any one of the following clinical syndromes – acute mania, acute and transient psychotic disorder, catatonia, or psychotic depression. The specific underlying disorder must be treated after ruling out medical conditions that can mimic PPP. In addition, PPP is also often severe in presentation with suicidal risk or risk of harm to the infant or others. This may often require in-patient care for adequate management of symptoms. The mainstay of management of PPP is usually an SGA which is compatible with breastfeeding. While SGA alone may suffice in case of acute psychotic presentations, psychotic depression may require the addition of an antidepressant. In case of mania, a mood stabilizer may be initiated. Catatonia is common in pregnancy and postpartum period. About 20% of women admitted in the perinatal period had catatonia as opposed to about 8% of admissions to acute in-patient psychiatric units.[28] The management of catatonia in pregnancy often presents with a particular difficulty in management because it necessitates the use of a benzodiazepine – lorazepam for its management. However, the symptoms of withdrawal and refusal to eat can cause dehydration, hypoglycemia, and electrolyte imbalance. The presence of stupor or immobility increases the risk of venous stasis and deep vein thrombosis during pregnancy. Therefore, the benefits of treatment with lorazepam often exceed the risks associated with its use for patients having reduced oral intake, rigidity and immobility.

Typically, management can be initiated with low-dose of lorazepam 3–8 mg/day (given in divided doses of 1–2 mg three or four times a day). In case of inadequate response over the first 24–48 h, the dose may be increased to 8–16 mg/day while monitoring for maternal pulse and blood pressure, and fetal heart rate. Further doses may be withheld if the maternal pulse is below 60 bpm or blood pressure is below 90/60 mmHg or fetal heart rate is below 100 bpm. When lorazepam is used, attempt must be made to reduce the dose and discontinue the medication while monitoring for symptoms of relapse. Another psychotropic medication must be initiated according to the underlying diagnosis. ECT is the other option for the management of catatonia that does not respond to lorazepam alone.

Table 9 summarizes the management strategies for various psychiatric disorders depending on the clinical aspects of the disorder in a given patient.

Table 9

Overview of preferred line of management for psychiatric disorders in the perinatal period

Disorder	Clinical aspects	First-line or primary treatment	Second-line or secondary treatment
Adjustment disorder OR Mild anxiety		Psychoeducation Psychotherapy (CBT/IPT) Follow-up and monitoring for symptoms	Medication may be considered for women with persistent symptoms, severe episode in the past or strong family history
Depressive disorder	Mild/single episode of depression - mild and in the past	Psychoeducation Psychotherapy (CBT/IPT Follow-up and monitoring for symptoms	Medication may be considered for women with persistent symptoms, severe episode in the past or strong family history
			Note - Always rule out any history of bipolarity such as milder highs, hypomanic episodes or a strong family history of bipolarity before starting an antidepressant
	Mild depression - active	Psychotherapy	Antidepressants if persistent symptoms or severe past episodes or strong family history
	Moderate to severe depression	Antidepressant medications (SSRI)	Psychotherapy (in combination with medication)
	Recurrent depressive episodes (≥4 episodes) OR recently remitted moderate to severe depression	Antidepressant prophylaxis	Psychotherapy and relapse prevention measures such as enhancing coping skills, stress management
Obsessive-compulsive disorder	Mild, amenable to ERP/CBT and prolonged remission	Continuing ERP/CBT booster sessions and medication-free follow-up	SSRI as antiobsessional medication may be used
	Severe or persistent with comorbid depression	SSRI may be considered for treatment and prophylaxis, if on clomipramine, the same may be continued while monitoring for any adverse effects	Add-on ERP/CBT may be considered
Bipolar disorder	Mania	Monotherapy with SGA	Mood stabilizer (lithium) - added if no response to SGA alone or on effective ongoing treatment with Lithium after discussing with the mother and family
	Depression	Monotherapy with SGA (olanzapine/other SGA) Use antidepressants with great caution because of a chance of postpartum relapse If depression is severe and does not respond to SGAs then consider a Combination of SSRI+SGA (eg., fluoxetine+olanzapine)	Mood stabilizer (Lithium) - added if no response to SGA alone or on effective ongoing treatment with lithium
	Remission	Monotherapy with SGA	Mood stabilizer (lithium) - added if no response to SGA alone or on effective ongoing treatment with Lithium
Schizophrenia	Exacerbation or episode	Monotherapy with SGA	Short term benzodiazepines may be required with nonsedating SGAs
	Remission or negative symptoms	Low-dose SGA	Psychosocial interventions
Catatonia	PPP, mania, or depression	Lorazepam may be preferred	Electroconvulsive therapy
			Treatment of underlying illness – mania or depression with either SGA/mood stabilizer/antidepressants as per clinical presentation

SGA – Second-generation antipsychotic; CBT – Cognitive behavior therapy; IPT – Interpersonal psychotherapy; SSRI – Selective serotonin reuptake inhibitors; ERP – Exposure and response prevention; PPP – Postpartum psychosis

MANAGEMENT OF ALCOHOL USE DISORDER DURING PREGNANCY

Fetal exposure to alcohol is associated with growth restriction, facial anomalies, and central nervous system dysfunction such as low intelligence and inattention-hyperactivity in the child. No level of alcohol use can be considered safe in pregnancy. Women must be educated about the risks of alcohol use and advised against drinking. Low levels of alcohol consumption may require brief intervention or motivational interviewing, however, those with moderate or high-risk use may require specialist deaddiction intervention.

Mothers with alcohol dependence who experience significant withdrawal symptoms can be treated with a short course of benzodiazepine medications. Lorazepam or diazepam may be considered for detoxification in case of severe withdrawal symptoms.

Long-term prophylaxis for relapse prevention relies on motivational interviewing and relapse prevention strategies. There is not much safety data to support the routine use of medications such as naltrexone or acamprosate. They may be prescribed in women who have a high risk of relapse. Disulfiram is avoided in pregnancy.

MANAGEMENT OF OTHER SUBSTANCE USE DISORDERS IN PREGNANCY AND POSTPARTUM

Cannabis use is associated with an increased risk of mood disorders, autism spectrum disorders, and inattention-hyperactivity in the offspring.

Tobacco use is associated with risk of preterm birth, low birth weight, and malformations of lips and mouth as well as risk of increased maternal bleeding during labour.

Psychotherapeutic methods are preferred for low levels of use. There is not much evidence for the safety of nicotine replacement therapy including patches and bupropion (FDA Category B) for the treatment of tobacco use disorders. Limited evidence suggests that they may not increase the risk of adverse neonatal outcomes.[29] The evidence for the safety of these medications is not extensive and hence treatment decisions must be taken on an individual basis.

SUICIDE IN PREGNANCY AND POSTPARTUM

The risk of suicide among women is higher in the 1st year after childbirth than any other time in their lives. Younger age, belonging to a middle socioeconomic status, poor perceived support, domestic violence, depressive symptoms, and having a past history of suicidality predict suicidal risk. Women are also more likely to use more lethal methods in the perinatal period. Suicidal risk and infanticidal risk may occur together and require attention. In-patient care may be considered along with ensuring the presence of family members and adequate social support to ensure a careful watch over the mother during the period of suicidal risk is essential.

Box 3 summarizes interventions specific and appropriate for women with suicidal risk in the perinatal period.

Box 3

Summarises interventions specific and appropriate for women with suicidal risk in the perinatal period

• Hospitalisation is needed in a high intensity care unit and temporary separation from the infant in a postpartum mother till risk for suicide decreases

• Ensure continuation of breast feeding as much as possible through expressed breast milk or infant visits to the mother and restitution of joint admission once suicidal risk decreases

• Use ECTs to enhance recovery if suicidality is in the context of depression or psychotic symptoms

• Educate family members about the high risk for self-harm and eyeball to eyeball monitoring till risk is found to decrease

• Twice daily risk assessments for lethality and intentionality

• Ensure that the ward or home is safe and no sharps are available

• Women at risk for suicide may want to take their infants and leave home or the hospital and utmost care needs to be taken to ensure safety

• Note - In high income countries one of the foremost reasons for maternal mortality is maternal suicide often due to a severe mental disorder

ECTs – Electroconvulsive therapys

MANAGEMENT OF AGITATION IN THE PERINATAL PSYCHIATRY SETTING

Agitation in the peripartum setting can put the mother and fetus/infant to risk of harm. Verbal de-escalation must be done first followed by oral medication such as lorazepam 1–2 mg or promethazine 25–50 mg or olanzapine 5–10 mg or chlorpromazine 50–100 mg. In case oral medications are not effective, intramuscular injection of lorazepam 2 mg or promethazine 25–50 mg or haloperidol 2.5–5 mg (in combination with promethazine to prevent dystonia) or olanzapine 10 mg may be considered. Regular monitoring of temperature, pulse rate, respiratory rate, blood pressure, and fetal well-being measures may be essential. Care should be taken to ensure that patient is lying supine with right hip elevation to avoid compromise of blood supply to fetus.

ELECTROCONVULSIVE THERAPY

The use of ECT during pregnancy may be life-saving in certain cases. Patients with catatonia or severe suicidal risk secondary to depression who do not respond to medical management alone may be considered for ECT. Some additional precautions taken during ECT in pregnancy are outlined in Box 4.

Box 4

Use of electroconvulsive therapy in pregnancy

Prior to procedure

• Obstetric consultation and clearance in addition to preanaesthetic check

• Overnight fast of 8 h may suffice

• Avoiding anticholinergic medications (as they reduce lower oesophageal sphincter tone) and use of oral antacids 15–20 min prior to procedure may reduce risk of gastric reflux

• Ensure adequate hydration with normal saline or ringer lactate

During procedure

• Preoxygenation is essential, but avoid hyperventilation to ensure adequate foetal oxygenation

• Anticholinergics - glycopyrrolate is preferred as it does not cross placenta

• Right hip is elevated (after 20 weeks gestation) to avoid aorto-caval compression leading to foetal blood flow compromise

• Monitor foetal heart rate by doppler just before and after ECT is administered. Twice weekly NST may be repeated

• Seizures do not lead to uterine contractions directly, but due to oxytocin release, painful contractions may occur. If persistent, tocolytics may be given

General

• ECT during pregnancy must be given in a setting where emergency obstetric and neonatal care is available readily

• In the postpartum period if ECTs are being given, ensure that the infant is fed before the procedure, the postpartum mother is prioritised in the ECT chart to receive the ECT early and expressed breast milk is available for infants

NST – Nonstress test; ECT – Electroconvulsive therapy

REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION

The safety of RTMS during pregnancy has not been widely studied, however, the few studies that have been done in pregnancy have not reported any adverse maternal or infant-related outcomes due to RTMS.[30]

MOTHER–INFANT BONDING INTERVENTIONS IN WOMEN WITH PSYCHIATRIC PROBLEMS

Many mother–infant dyads will have been separated from each other or may have difficulties in forming attachment because of a mental health problem in the mother. Early attachment problems are a risk for later externalizing and internalizing problems in the child and other emotional difficulties in adolescence and adulthood. Adequate attention should be paid to the assessment of bonding using the instruments mentioned above and a good clinical interview. If a bonding problem is found interventions include education about the same training in infant care, modeling, video-enabled feedback training, and in case of a severe problem, mother–infant psychotherapy. Having an additional caregiver such as a grandmother or father is often beneficial.

IN-PATIENT CARE OF PERINATAL MOTHERS AND THE MENTAL HEALTHCARE ACT 2017

The Mental Healthcare Act, 2017 recommends the least restrictive option for patient care. Therefore, outpatient care is preferred in mild psychiatric illnesses or exacerbations. However, in moderately severe illness episodes or exacerbations, inpatient care may be required to ensure safety of mother and infant. When inpatient care is provided to a mother with low risk of suicidal or infanticidal risk, rooming-in of mother and child (under 3 years of age) is recommended as per Section 21[2] of the Mental Healthcare Act, 2017. In case a decision to separate the mother and baby is made by the treating psychiatrist based on information available regarding the patient’s illness and an assessment of the patient’s clinical condition; the decision must be reviewed every 15 days. In case the separation must continue beyond a period of 30 days, the Mental Health Review Board must be informed and permission sought for the same.

MBUs are in-patient units with at least four in-patient beds which allow the rooming-in of mothers and their infants or children under the age of 3 years and are run by a multi-disciplinary team of psychiatrists and allied health professionals. The requirements of setting up an MBU in India have been outlined by Chandra et al., 2015.[31] There may be a need to set-up MBUs in the future.

CONCLUSION

The role of a psychiatrist in the care of mothers with mental illness broadly includes evaluation and management of mothers with (i) psychological issues related to all aspects of pregnancy and childbirth such as infertility and its treatment, traumatic experiences related to pregnancy and childbirth; (ii) management of new-onset psychiatric conditions in the perinatal period; and (iii) management of preexisting psychiatric illnesses in mothers planning pregnancy.

The major decisions regarding choice of treatment is taken based on risk-benefit analysis of the treatment of the psychiatric condition against the risks of untreated psychiatric illness in the mother. In general, the benefits of prophylaxis for mothers with SMI exceed the risks. Individualized decision may need to be taken in each case. The new legislation, Mental Healthcare Act 2017, encourages the setting up of specialized MBUs for the joint admission of mothers with their infant or children under the age of 3 years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.